Reducing MRSA Infections: Staying One Step Ahead

When it comes to fighting certain serious infections, the efforts of patients and providers alike can sometimes take on heroic proportions. This is especially true when the stakes are high and the infection is not easily eradicated. Infections caused by bacteria are a case in point. They are challenging to cure because some strains have become resistant to many first-line antibiotics. Staph infections can start mildly enough — perhaps a mere boil on the skin — but can then spread quickly to produce extensive, potentially fatal skin and soft tissue infections or through the bloodstream to the lungs, bones, kidneys or heart. Staph infections are associated with substantial suffering, death, and cost.
The most commonly identified multidrug-resistant strain of Staph cropping up in hospitals worldwide is methicillin-resistant Staphylococcus aureus (MRSA). Labeled a super bug because it is resistant to so many antibiotics, MRSA is a formidable enemy: It is about two-and-a-half times more lethal than infections that are treatable with methicillin, and its incidence has increased dramatically in the past decade. ICUs are the most common site of infectious outbreaks, but MRSA can show up just about anywhere in hospitals. In addition, a separate strain called community-acquired MRSA is also showing up more frequently in community settings, especially among people who live or work communally such as athletes, prisoners, children, and military personnel.
According to the Centers for Disease Control and Prevention (CDC), in 1974 MRSA infections accounted for just two percent of the total number of Staph infections. Today, MRSA accounts for more than 60 percent of Staph infections. A study released in June 2007 by the Association for Professionals in Infection Control and Epidemiology (APIC) estimates that at least 5 percent of US patients — about 30,000 people — may be infected with or carrying the bug at any given time. And MRSA is by no means a challenge that only US hospitals face; numerous studies show MRSA is on the rise worldwide.
Methicillin seems to be following the path of its predecessor drug in the treatment of Staph infections: In 1950 penicillin was effective against 100 percent of Staph strains. By 1985 the miracle drug was effective against less than 5 percent of such strains. Today, MRSA is resistant not only to penicillin, but frequently to erythromycin, clindamycin, ciprofloxacin, and other quinolone antibiotics as well. Some strains have been reported to be resistant even to vancomycin (the go-to drug in the past for resistant strains) and one of the newest drugs on the market, linezolid.
The Institute for Healthcare Improvement believes that hospitals that implement known best practices in combating MRSA can reduce its spread. Combating MRSA is a key component of IHI’s 5 Million Lives Campaign, focused on reducing medical harm.  
A High Price
The human and financial toll that MRSA exacts is high. More than 126,000 hospitalized patients are infected annually, and IHI estimates that more than 5,000 patients die each year as a result. While most patients are treated successfully, particularly if the infection is identified early, hospital stays are often extended by an average 9.1 days, accounting for excess costs of about $20,000 per patient. The total cost burden to the US health care system from MRSA infections is estimated at more than $2.5 billion annually.
The epidemiology of MRSA has changed in recent years, making it increasingly tricky to detect and manage. A study published in 2002 showed that cases of community-acquired MRSA infections in children in south Texas increased fourteen-fold between 1999 and 2001. Patients with community-acquired MRSA infections are showing up in hospital emergency departments and outpatient clinics in increasing numbers. The New England Journal of Medicine published research in 2005 showing that between 8 and 20 percent of patients isolated for MRSA infections in hospitals in three major US cities acquired the infection in the community.
To further complicate matters, about two percent of the population is estimated to harbor the MRSA bacteria but, because they are healthy enough to resist infection, have no idea they are carrying something that can expose and harm others. When these “colonized” individuals enter the hospital (typically for an unrelated reason), they bring MRSA with them.
Since these patients are asymptomatic, health care professionals who care for them do not take extra precautions as they would with patients known to be infected, and inadvertently spread the bacteria to other patients who may be sicker, older, weaker, and more vulnerable to infection. In fact, the principal mode of spreading MRSA in hospitals has been found to be the contaminated hands of caregivers.
The 5 Million Lives Campaign’s How-to Guide on reducing MRSA offers a number of steps designed to stem the spread of this infection. The Guide calls for caregivers to use effective hand hygiene practices; decontaminate the environment and equipment; perform active surveillance cultures; use contact precautions for infected and colonized patients; and implement device bundles such as the Central Line Bundle and the Ventilator Bundle.
(For references, please see IHI’s 5 Million Lives Campaign How-to Guide: Reduce MRSA Infection.)
Hospitals that have systems in place to support these best practices are seeing encouraging results. For example, in a collaborative effort among the Veteran’s Administration Pittsburgh Health System (VAPHS), the Pittsburgh Regional Health Initiative, both in Pittsburgh, Pennsylvania, and the CDC, a “bundle” of interventions was implemented, including standard precautions, hand hygiene, active surveillance cultures, contact precautions, and an emphasis on culture change using briefings on patient care units, leadership involvement, and other strategies. There was a 70 percent decrease in MRSA infection on one patient care unit.


graph_1MRSA rate.jpg 


Similarly, in the Repatriation General Hospital in Adelaide, South Australia, the MRSA rate dropped dramatically over a four-year period (including a 105-day stretch where there were no hospital-acquired MRSA cases at all), as effective processes were reliably implemented throughout the hospital.




And Parkland Medical Center in Derry, New Hampshire, has had similar success:


Effective Hand Hygiene

The importance of improving hand hygiene has finally become a priority at most US hospitals, thanks to increasing awareness that compliance with proper procedures has been historically low. Despite noteworthy examples of compliance rates now as high as 90 percent at some hospitals, experts estimate that on average US health practitioners still only comply with recommended hand hygiene procedures less than 50 percent of the time. Hand hygiene improvement advocates say this has to change because proper hand hygiene is the single most effective means of reducing hospital-borne infections, including MRSA.
And to drive this point home, experts say, comprehensive education is key. Guidelines call for health care professionals to clean their hands both before and after patient contact. Most caregivers don’t know they should do both. Many also don’t know they should clean their hands after they remove protective gloves. (For detailed information about current hand hygiene protocols, see the How-to Guide: Improving Hand Hygiene. Also see the Agency for Healthcare Research and Quality's Podcast on Hand Washing.)
In addition, new products such as alcohol-based gels and foams have changed everything. “We found a big knowledge gap when we began using the alcohol hand rub,” says Candace Cunningham, RN, MRSA Prevention Coordinator at the Veteran’s Administration Pittsburgh Healthcare System. “Most people felt that washing with soap and water was superior, when the alcohol products are actually proven to be more effective.” While antimicrobial soap and water are still recommended for hands that are visibly soiled or have been exposed to bodily fluids, alcohol-based gels or rubs are now preferred for routine decontamination of hands after most patient contact (but not after contact with a patient who has antibiotic-associated colitis due to Clostridium difficile). These products rapidly kill bacteria and most viruses, and actually are gentler on the hands than repeated use of soap and water. 
Karen Cozzens, RN, MSN, CIC, Infection Control Director at Parkland Medical Center in Derry, New Hampshire, admits she found it hard at first to believe that alcohol products eliminate bacteria better than soap and water. “So I did a hand hygiene experiment,” she says. “I got 12 volunteers, and I cultured their hands before and after washing with antibacterial soap and water, and before and after using the alcohol rub.”
The results? “I was shocked,” she recalls. “The results were consistent and dramatic and convincing. With soap and water there were still many bacteria colonies afterward, but after hand rub there were virtually none.”
Now she uses pictures of the culture plates at staff orientations to drive home the importance of using proper hand hygiene procedures and products.
Placing alcohol rub dispensers in convenient locations makes it easier for people to change old habits. “Our staff is our best resource when it comes to improvement,” says the VA’s Candace Cunningham. “They are the experts. So we asked them where the alcohol rub dispensers should be placed.” With staff input, Cunningham says the hospital dramatically expanded the number of dispensers throughout the facility, even adding them to family and visitor areas, lobbies and near elevators, with signage encouraging all visitors to use them.
IHI Director Fran Griffin, RRT, MPA, who works with hospitals on reducing the incidence of MRSA, says it’s important to evaluate traffic patterns and human behavior in choosing the right place for dispensers. “One hospital was trying to figure out why the dispenser they placed outside the ICU wasn’t getting much use,” she says. “When they watched the traffic patterns, they learned that people approaching that door were often reading something — a lab report, or their Blackberry — and missed the visual cue of the dispenser.” When the dispenser was moved to a location more likely to be seen, usage increased. “Human factors are essential considerations in designing reliable processes,” says Griffin.
Reinforcing good hand hygiene procedures requires ongoing vigilance and monitoring. Measurement strategies include monitoring the use of products (some dispensers have counters in them to track the number of actual uses) and unannounced observation, as well as random auditing of specific aspects of the process (for example, the accessibility of gloves in all sizes, or the presence of visible hand hygiene reminders). At the Repatriation Hospital in Australia, chief infection control nurse Patricia Roberts, RN, says that the hospital has been able to track a correlation not just between hand hygiene compliance and reduced MRSA rates, but more specifically with the amount of gel that is used. “We have found that gel usage is an even more sensitive indicator than compliance,” she says, a finding that prompted more in-depth education on proper hand hygiene techniques by the hand hygiene champions on each unit.  
Getting patients involved in promoting hand hygiene can also be effective, says Jon C. Lloyd, MD, FACS. Lloyd is MRSA Prevention Coordinator at the Veteran’s Administration Pittsburgh Healthcare System, and the Regional MRSA Prevention Coordinator for the CDC.  He is also a strong advocate of encouraging staff and patients to develop strategies that improve care.  
At the VA Medical Center in Lebanon, Pennsylvania, for example (one of the VA’s six beta-site hospitals using an innovative approach to cultural transformation focused on preventing healthcare-acquired MRSA), staff and patients on a 30-bed rehabilitation unit collaborated to create a friendly competition to encourage proper hand hygiene. “All staff are given a booklet of ‘no MRSA’ stickers,” he says. “There is a dispenser of alcohol-based rub inside the door of every room, and patients are told to ask for a sticker from any staff person who forgets to use it when they enter and as they leave,” he says. “The original plan was to offer coupons for the hospital’s snack bar as prizes to the patient who collected the most stickers after two weeks and the staff member who retained the most.” Lloyd reports that compliance with appropriate hand hygiene practices increased so quickly and dramatically on this unit that the game was extended. Rather than giving individual prizes, the hospital sponsored a pizza party for the unit and presented the staff with a group recognition award. The game is reactivated as needed periodically as a boost.  
Decontamination of the Environment and Equipment
Because MRSA survives well in a hospital environment, people can contaminate their hands by touching contaminated surfaces and objects. Patients can occasionally acquire MRSA in a room whose previous occupant was colonized or infected. Thorough and frequent cleaning of the room and equipment is a critical element in keeping MRSA at bay.
Karen Cozzens at Parkland Medical Center in New Hampshire works closely with the hospital’s environmental services staff to make sure they understand their critical role in keeping patients infection-free. “They receive quite a bit of training and education on environmental precautions and hand hygiene,” she says. “They are not just housekeepers, they are part of the team. I remind them and everyone else how important their role is.”
Comprehensive policies and procedures, as well as checklists and evaluative tools, help the environmental services staff maintain high standards, which include twice-daily cleanings in rooms where patients are on contact precautions, with a particular focus on “high-touch” areas such as door knobs and bed rails. In addition, the bedside curtains in these isolation rooms are cleaned at discharge. Dedicated patient care equipment for colonized or infected patients, such as stethoscopes, thermometers, and blood pressure cuffs, also minimizes the opportunities to carry MRSA from room to room.
Active Surveillance Cultures
Identifying colonized patients is a key component of reducing the spread of MRSA. While infected patients are often positively identified in the course of having their clinical specimens analyzed (for example, wound, blood, or urine samples), colonized patients are far more likely to become known through “active surveillance cultures” — routine screening of patients on admission by taking a culture from the most common reservoir site for colonized MRSA: the nose.
Culturing all admitted patients is costly and labor-intensive, but some hospitals that follow these procedures claim significantly reduced MRSA rates that pay off financially as well as clinically. Hospitals that target high-risk groups for screening focus on patients admitted from long-term care facilities, people who’ve been hospitalized within the past year, or those with skin wounds. Don Goldmann, MD, an infection control expert and Senior Vice President at IHI, points out that screening only high-risk groups can be effective but will miss a substantial proportion of colonized patients.
In addition, says Goldmann, nasal cultures can miss patients who are colonized on other body parts, such as the armpit, rectum, or groin. But whatever surveillance strategy a hospital chooses, says Goldmann, “knowledge is power.”
“Active surveillance cultures are the best way to document the extent of the problem on a particular unit or in the hospital as a whole, while culturing the patients again at the time of discharge can help assess the success of the hospital’s infection control effort,” says Goldmann. An effective program, he says, incorporates reliable hand hygiene, contact precautions, and environmental cleaning and disinfection, as well as excellent compliance with central venous catheter and ventilator care. “It’s the combination of these steps, performed reliably, that can rapidly reduce the percentage of patients who acquire MRSA while they are in the hospital.”
Nonetheless, Goldmann points out that epidemiological evidence on the effectiveness of active surveillance cultures in reducing MRSA transmission in hospitals is not yet conclusive, and that attempts by some states to legislate MRSA screening are premature. “The experience from a growing number of hospitals suggests that there is benefit, but a recent randomized controlled trial in ICUs demonstrated no impact,” says Goldmann.
“This could have been because culture results were delayed, or perhaps because compliance with hand hygiene and other infection control practices was not ideal. For active surveillance cultures to be truly cost-effective, the other components of infection control practice, such as hand hygiene and contact precautions, must be performed with high reliability. There is no single magic bullet.”
Goldmann also warns hospitals to keep an eye on other antibiotic-resistant pathogens, such as Pseudomonas and Acinetobacter, which can be even more resistant to antibiotics and virtually impossible to treat. 
To identify patients who may have acquired MRSA while in the hospital, some hospitals re-screen MRSA-negative patients when they are transferred or discharged. This is done at several hospitals in southwest Pennsylvania, says the VA’s Jon Lloyd. “We have 20 hospitals in the area that have started doing targeted surveillance, and four have taken it house-wide, screening at admission, discharge, transfer, and death,” says Lloyd. “Some might call it process overkill, but we think it’s good to know exactly what our MRSA burden is. Fewer than 50 percent of all MRSA-positive patients in our regional experience are identified by clinical cultures. More than 50 percent of our MRSA patients are asymptomatic [colonized] and we wouldn’t know about them if we weren’t doing house-wide surveillance.”
At Newark Beth Israel Hospital in Newark, New Jersey, MRSA screening is done on all babies admitted to the neonatal intensive care unit (NICU), says Jeremias L. Murillo, MD, the hospital’s epidemiologist. “In July 2005 we had a mini-epidemic with six babies infected in about a week,” he recalls. “We figured they might already be coming in colonized, and that gave us the impetus to start screening.” While most babies are successfully treated for MRSA, it lengthens their stay and challenges their fragile systems.
In the first year of screening, 22 colonized babies were identified, and further testing showed that their mothers were often also colonized at the time of their birth. Colonized babies are now decolonized with a topical antibiotic (mupirocin), and mothers are now tested prior to delivery (with about 10 percent testing positive) and treated if necessary. “After a year in which we had 20 MRSA infections in the NICU, with our new procedures we went 15 months without one,” says Murillo. “We had one recently, but we think from testing it may have come in with the mom, who was discharged weeks before and may have acquired it in the community.”
Murillo says his hospital spread the process to the adult ICU, where initial screenings showed that about 30 percent of admitted patients tested positive for MRSA. Now, all patients who test positive are decolonized.
Routinely decolonizing all patients who test positive is discouraged by some experts because broad use of mupirocin, the antimicrobial used to eradicate nasal colonization, has led to resistance. Moreover, decolonization is very difficult in patients who are colonized in the rectum or have MRSA in the sputum, pressure ulcers, wounds, or other sites. IHI’s Goldmann says that selective treatment of colonized patients who are about to have elective surgery, especially if a foreign body is to be implanted, may make more sense as the risk of colonization with community-acquired MRSA strains increases.
Jon Lloyd at the VA in Pittsburgh says his hospital does not decolonize all MRSA-positive patients. Rather, they focus on a subset of patients. “We are piloting active surveillance and decolonization on patients having total joint replacements, major vascular procedures, and cardiovascular or neurological surgery,” he says, “based on untested information from the CDC. We don’t have evidence yet to make this a standard, but we hope to learn something.”  
Whether a colonized patient is decolonized or not, it remains important that appropriate precautions are taken to prevent the spread of MRSA bacteria to other patients.
Contact Precautions for Infected and Colonized Patients
Patients who are colonized with MRSA, and particularly those who are actually infected, should be placed in a single-occupancy room to reduce the likelihood of the bacteria’s spread. Caregivers should rigorously practice effective hand hygiene, don gloves and gowns when they enter the room, and discard them upon leaving.
When hospitals lack sufficient private rooms, MRSA-colonized patients can be placed in semi-private rooms and contact precautions must be strictly observed. Here again, says IHI’s Fran Griffin, visual cues can help. “One hospital uses red tape on the floor around the area of the patient’s bed,” she says. “Staff know that they must use contact precautions if they cross the red line. It’s not based on whether or not they even touch the patient.” At Parkland Medical Center in New Hampshire, Infection Control Director Karen Cozzens says all patients on contact precautions get a special green isolation wristband, so that anyone who comes into contact with the patient knows to be especially vigilant.
The challenge here is one of timing: It can take 48 hours or longer to grow a MRSA culture. Some hospitals opt to preemptively place all newly admitted patients on contact precautions pending the outcome of their screening test, but this can be costly both in terms of supplies and extra staff time. Others use gloves for all contact with patients until the results of the screening are back. In either scenario, says IHI’s Fran Griffin, “the key is to make sure you have systems in place to get real-time notification about MRSA-positive patients to the front-line staff as quickly as possible.”
Still other hospitals are opting for a newer technology that provides results of MRSA testing within a few hours. Called polymerase chain reaction (PCR) assay, it requires a significant investment in new lab technology, but Dr. Jeremias Murillo at Newark Beth Israel Hospital says it pays for itself in the savings from fewer MRSA infections. “A lot of hospitals struggle with this,” he says. “They can’t get the new machine because it’s too expensive. But in our NICU, we’ve probably saved $500,000 in one year by reducing our infection rate so dramatically.” And it means that babies get treatment more quickly, and don’t have to be in isolation a moment longer than necessary.
Device Bundles (Central Line Bundle and Ventilator Bundle)
Patients with invasive devices such as central venous catheters and ventilators are at greater risk for developing hospital-acquired infections, both because of the invasive devices, and the severity of their underlying illnesses. For these patients who may be colonized with MRSA, the risk is increased and extreme care must be taken to prevent infection.
As part of it’s 100,000 Lives Campaign and now the 5 Million Lives Campaign, IHI developed and disseminated information about the implementation of “bundles” — groupings of best practices that individually improve care, but when applied together result in substantially greater improvement.
The steps in the Central Line Bundle and the Ventilator Bundle, both of which have been proven effective at reducing infection, are specified in their respective How-to Guides. 
A Group Effort
As in every large-scale improvement process that affects many or most areas of a hospital, reducing MRSA infections requires strong leadership. “There has to be a champion,” says Jeremias Murillo. “It’s difficult to convince people that these steps will work. People are tempted to throw in the towel on MRSA, and you need someone to keep driving forward.”
But at the same time, says Jon Lloyd at the VA in Pittsburgh, the importance of staff participation and engagement can’t be overstated. “The more the staff are able to become the experts on overcoming barriers, the more durable the solutions will be.”
At Parkland Medical Center in New Hampshire, Karen Cozzens says that one of the unexpected benefits from their efforts to reduce MRSA has been staff empowerment. “Nurses didn’t used to put patients on isolation precautions without a physician’s order,” she says. “Now they use critical thinking to decide whether to place someone on precautions while awaiting culture results. The environmental services staff are so knowledgeable, and they don’t hesitate to call me if something doesn’t look right, like a missing isolation sign. It’s great to be able to work with staff like this.”
At the Repatriation General Hospital in Adelaide, the information technology staff have made a significant contribution to the hospital’s efforts to combat MRSA, says Dr. Chris Farmer, the hospital’s Director of Medical Administration. “Working with the infection control staff, they built a highly integrated, extremely broad infection control system that works as a management tool for MRSA and surgical site infections generally,” he says. “It tracks pathology databases, searches reports and immediately highlights to infection control staff any positive results. It can track where a patient came from and where they’ve been in the hospital, and it stores data historically so when MRSA patients are readmitted they are identified as a MRSA risk. It produces a comprehensive suite of reports for performance management purposes.”
Chris Farmer says the system’s cross-infection matrix allows staff to “get out ahead” of an epidemic by tracking who MRSA patients have been in contact with during their hospital stay. “The tracking system has helped us enormously. Within minutes we know who might have been exposed and where they are for rapid screening and isolation purposes. We’ve gone from fighting fires and chasing paperwork to getting computers to do the administrative workload, so the infection control staff can do what they should be doing.”
Hospitals that have been successful at beating back MRSA share a common culture that emphasizes teamwork and the possibility of excellence. “We talk about getting to zero,” says Chris Farmer in Australia. “Some people can’t believe we can do it, but we’ve seen it. We’ve achieved perfection for periods of time, and now the challenge is staying there.”
The cultural transformation at the VA in Pittsburgh became evident to Jon Lloyd when he attended a staff meeting about preventing MRSA that included more than 100 health care workers from all specialties and vocations. “At our first meeting, we asked the staff who was responsible for infection control. Most people pointed to our Infection Control people. A year later, we posed the same question to a similar group. Almost every hand in the room went up.”



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